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Date run 1/31/2017 3:09:43PK SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by <br /> Facility Information as of 1/31/2017 Paget <br /> Record Selection Criteria: Facility ID FA0011046 <br /> Make changes/corrections in RED ink. �/ <br /> INFORMATION CHANGE(date) J 17 <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 2 SSN/Fed Tax ID : <br /> Owner ID OW0009045 Case Number: H09209 New Owner ID <br /> Owner Name HOUSING AUTHORITY OF SJ COUNTY <br /> Owner DBA HOUSING AUTHORITY OF SJ COUNTY <br /> OwnerAddress 741 S BELLEVIEW ST <br /> STOCKTON, CA 95206 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-460-5063 <br /> Mailing Address 421 S EI Dorado St. <br /> STOCKTON, CA 95203 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0011046 10184061 <br /> Facility Name SIERRA VISTA HOMES HACSJ <br /> Location 2424 S BELLEVIEW ST <br /> STOCKTON, CA 95206 <br /> Phone 209-670-4757 x <br /> Mailing Address 421 S El Dorado St <br /> Stockton, CA 95203 <br /> Care of Fabiola Davis <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA, CARLOS Fax <br /> APN 16927002 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0018046 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name SIERRA VISTA HOMES HACSJ (Circle One) <br /> Account Balance as of 1/31/2017: $344.00 <br /> (Circle One) <br /> Transfer to Achumnaclve <br /> lament and Description Record ID Employee ID and Name Status New OwneR Delete <br /> BP-Regular-Primary Location PRO520631 EE0009817-ROBERT LOPEZ A lve N A I D <br /> 2220- HW GEN<5 TONS/YR PRO514505 EE0000026-CESAR RUVALCABA N//_' I D <br /> -HAZ MAT BUSINESS PLAN AUTHORIZATION PRO513334 EEOOO0000-HAZ MAT SJC OES Ina Iv Y N `� I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FI PRO511046 EEOOO000o-HAZ MAT SJC OES Inactive Y N A I D <br /> 2840-AST EXEMPT FAC < 1,320 GAL PR0531190 EE0001421 -STACY RIVERA Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PR0534314 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of same,acknowledge that all site,andor project spacfiq PHSEHD hourly charges associated with this facility <br /> or activity,will be billed to the party da rtifed as Ne OWNER on this form. I also cenify Net all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State andor <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date I / <br /> Program Records to be TRANSFERED: •$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date / / <br /> Payment Typ Check Number Received tily <br /> EHD Staff: Date / / Account out: Date / / / I <br /> COMMENTS: n / -/q1/ (_ D <br /> K L Invoice#: 7 Y' <br /> / e? 0e,i a/f4c>-'. oT w�Lf'T o.• /06S Qs�'`/eee IzlL I/I (�. <br />